Managing COPD as a long term condition: emerging learning from the national improvement projects

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Managing COPD as a long term condition: emerging learning from the national improvement projects

Managing COPD as a long term condition: emerging learning from the national improvement projects

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  • 1. NHSCANCER NHS Improvement LungDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - LungManaging COPD as aLong Term Condition:Emerging Learning from theNational Improvement Projects
  • 2. Patients and their carers are the reason the health service existsand therefore they should be at the heart of our services. Serviceredesign and improvement generate opportunities to involveservice users who will provide a different perspective on theservice, so that we can better understand whether our service orimprovements make any difference to the patient.Only when we understand patients’ needs – by asking them, notsecond guessing – can we work in a way that meets those needsand ensures they get maximum benefit from our service.
  • 3. 3Managing COPD as a Long Term Condition - EmergingLearning from the National Improvement ProjectsContentsForeword 4Executive summary 5Improvement stories: Improving patients’ ability to self manage 8 Key messages 8 ‘Think ABC To self manage your COPD’ – One practice’s approach to improve patients’ management of exacerbations: Veor Surgery, Camborne, Cornwall 9 Embedding the use of effective self management approaches in primary care: NHS Blackpool 11 How can support groups increase patients’ ability to self manage? NHS Stoke on Trent and North Staffordshire Breathe Easy Group 14 The role of secondary care in increasing consistent use of self management plans to reduce outpatient attendance and emergency admission: Southampton University Hospitals NHS Trust 16Improvement stories: Management of COPD 18 Key messages 18 Systematic review of patients’ inhaler technique and medication use: Victoria Practice, Aldershot, Hampshire 19 How can respiratory specialists support primary care to improve management and reduce admissions? Imperial College Healthcare NHS Trust & Central London Community Healthcare NHS Trust 21 Earlier identification of COPD patients & preventing inappropriate admissions: Surrey Community Healthcare 23 Supporting people with moderate or severe COPD to self manage through clinical and behavioural interventions: NHS West Sussex 25Data 27 Why is data so important? 27 What have we learned about data from the project sites? 28Improvement stories: Turning data into information for improvement 33 Key messages 33 Understanding variation in primary care management of COPD - Using practice data to make the case for change: Leicestershire County & Rutland PCT in conjunction with OPC – Optimum Patient Care 34 Using information to target support to practices and patients, in order to reduce variation in diagnosis and management of COPD – NHS Sheffield 37Top tips for COPD management projects 40Top tips for service improvement 42Contact details 44Acknowledgements 45
  • 4. 4 ForewordForewordSince July 2010, NHS Improvement – This publication contains information forLung has worked with a number of healthcare professionals and thoseclinical teams across England as part of working in commissioning or interfacingthe Department of Health Respiratory with COPD services. This includes thoseProgramme. Its aim has been to support who are:the development of patient centred,evidenced based and clinically led services • Involved in the care of patients whoby identifying and sharing innovative require COPD servicesways to reduce variation in care and • Responsible for commissioning COPDimprove the quality and experience of services Professor Sue Hillpatients with chronic obstructive • Managing COPD servicespulmonary disease (COPD). • Local or regional leadsThe national improvement projects have The project sites were encouraged totested approaches at key stages of the employ a range of service improvementclinical pathways which have included: tools and techniques. These included process mapping, demand and capacity• Improving home oxygen services and data analysis, the application of Lean• Early accurate diagnosis principles, process redesign and the• Transforming acute care human dimensions of change. NHS• Managing COPD as a long term Improvement - Lung also supported the condition testing of new ideas and pathways• Improving end of life care through site visits and project team peer support. Dr Robert WinterFollowing the first six months of theimprovement programme, this There are lots of practical examples withinpublication signals the mid-way point in this report to support clinical teams inthe project cycle and has been written to delivering quality and productivityshare the learning from the testing phase benefits to patients and a wider range ofof the work. Through a series of case stakeholders. Over the next six months,studies and examples, it aims to highlight NHS Improvement – Lung will continue toareas of innovative and emerging good test the key principles for change andpractice that can be used locally to deliver implementation. As this learningimprovements for COPD patients and emerges, it will be shared with COPDtheir carers. services and the wider NHS.In order to address the paucity of current We would like to take this opportunity toevidence, particularly around the models thank the project sites for their hardand principles of implementation, the work, dedication and commitment andprogramme will continue to adapt and look forward to the full extent of therefine the learning. However, these improvement work as it comes to fruition.lessons will be of value now to any teamworking to improve the care it deliversand commissions for people with COPD.The publication contains a number ofexamples that demonstrate value for Professor Sue Hillmoney, increased productivity and Dr Robert Winterapproaches that can sustain Joint National Clinical Directorsimprovements over the long term. for the Respiratory Programme
  • 5. Executive summary 5Executive summaryChronic obstructive pulmonary disease Summary of emerging learning that issues of significance to the patient are(COPD) is a progressive disease and cannot The early learning from the project sites to also explored, and this is highlighting thebe cured. However it can be treated, and date demonstrates some of the practical need to consider how best to providewith the right care the impact of the disease issues around implementing those elements regular review for those patients with co-can be modified1,2,3. In particular, effective of supported self care and good chronic morbidities. It is essential that supportmanagement of medications, regular disease management that we already know between reviews is also optimised, and earlyreview, care planning and self management to be effective. This highlights not only indications are that a systematic approachcan help people cope with their disease and what works and how people are doing it, to provision of rescue medication andreduce the need for hospital admission. but also what barriers still exist and where follow up for exacerbations can reduce we still need to find solutions to enable demand for GP urgent appointments orThe intention of NHS Improvement - Lung’s people to adopt best practice. home visits, as well as admissions for someworkstream on Managing COPD as a Long patients. Optimising medications use, alongTerm Condition is to demonstrate how self Improving people’s ability to self with systematic and opportunistic checks ofmanagement, regular review and medicines manage: Implementing effective support inhaler technique, and regular staff trainingmanagement can best be delivered and for people to manage their condition more in how to demonstrate it, can furtherhow they can affect outcomes and use of effectively requires time, excellent improve patient adherence and reducehealthcare resources. This in turn can communication and motivational waste, with cost savings of 10%improve patients’ experience, the interviewing skills, as well as focused effort. demonstrated in one site.progression of their disease and their need Early indications are that a comprehensivefor hospital admission when their condition consultation of at least 30 minutes – and Use data to make a difference: COPDflares up. probably 45 to 60 minutes – is required to exacerbations are not consistently coded in establish rapport with the patient and general practice but addressing this allowsThe recently published outcomes strategy identify the issues that need to be rapid identification of patients whosefor people with chronic obstructive addressed in order to have greatest impact. condition is beginning to deteriorate and ofpulmonary disease (COPD) and asthma4 This is a challenge for teams to implement how well exacerbations are being managed.highlights the need to focus on high quality within existing resources and ways of doing A key indicator is the proportion ofcare and support, in particular the effective so need further exploration and testing. It exacerbations resulting in admission – goodmanagement of patients with COPD using also appears that working closely with a management means exacerbations arechronic disease management approaches. team and a group of patients appears to recognised, but early intervention shouldIn this initial phase of the programme, the have greater impact than a large scale roll mean fewer admissions and lower length ofprojects have been exploring the reality of out of a common approach, which can take stay. Significantly more information ismaking this happen – systematically taking longer to become embedded in practice. available from primary care systems than isstock of current practice and understanding Various self management plans have been captured by practices’ Quality andhow to ensure that patients receive optimal developed and are in use, and clear Outcomes Framework (QOF) score and thiscare, in a climate where there are limited documentation of a self management plan can be used to highlight how well COPD isresources. helps ensure a consistent approach, but the being managed across primary care, the real key is professionals’ approach to the marked level of variation that exists and theThis interim publication summarises the planning that they do with the patient, impact that this has on secondary care usework of the projects at the mid point of rather than the plan documentation itself. and prescribing. While providing the datatheir duration, and highlights the early alone does not instigate change in practice,learning and emerging themes that will Management of COPD: Making time for it does allow a much more comprehensiveinform the next stage of work. This learning a comprehensive consultation including self picture of the current position to bemay also be helpful for both primary and management support ensures that patients’ developed and intervention to be targetedsecondary care in supporting their regular reviews are of maximum value. to drive up quality and reduce waste.commissioning plans, with its emphasis on Various templates are becoming available topatient centred care and delivering the support clinical checklists, but it is importantquality, innovation, productivity, prevention(QIPP) and safety agenda.
  • 6. 6 Executive summarySummary of projects Leicestershire County & Rutland Primary Many of the measures outlined in thisVeor Surgery, Cornwall: Trialling a Care Trust with Optimum Primary Care: document are designed to support the NHSsystematic approach to improving patients’ Understanding variation in primary care to meet the QIPP challenge, either byrecognition and management of management of COPD and using practice identifying where resources might beexacerbations using self management data to make the case for change. released or by improving understanding ofaction plans and rescue medication. the key interventions that have greatest NHS Sheffield: Using information to effect.NHS Blackpool: Developed a target support to practices and patients, incomprehensive self management plan with order to reduce variation in the diagnosis Success for many of the Managing COPDpatients and tested ways to embed use in and management of COPD. projects will be indicated by their impact onprimary care. frequency or severity of exacerbation, and Quality Innovation Productivity and the proportion of exacerbations that resultNHS Stoke on Trent & North Prevention (QIPP) and expected in admission, as well as by patientStaffordshire Breathe Easy Group: outcomes satisfaction measures.Exploring what impact patient support Demand for healthcare is increasing andgroups can have on people’s use of health there are areas where we could increase the Early examples of QIPP impact include:care resources and their ability to self quality, efficiency and value for money of • A systematic approach to selfmanage. services as well as improving outcomes for management and early intervention for people with COPD. Efforts need to be exacerbation is beginning to demonstrateSouthampton University Hospitals concentrated on three components to make a reduction in the proportion ofNHS Trust: The role of secondary care in this possible. First, improving quality whilst exacerbations admitted, releasingimproving patient self management to improving productivity, using innovation capacity in secondary carereduce outpatient attendance, emergency and prevention to drive and connect them. • In secondary care or specialist teams,admissions and readmissions. Second, having local clinicians and targeted intervention with those patients managers working together across who have repeated admissions is alsoVictoria Practice, Aldershot: Testing the boundaries to spot the opportunities and beginning to demonstrate reduction inimpact of a practice clinical pharmacist in manage the change. Finally, to act now for admissions.systematically reviewing patient inhaler the long term. • Similarly systematic medicinestechnique and medication use to improve management, inhaler techniqueoutcomes and make best use of resources. The ambition is to achieve efficiency savings education and medicines review is of up to £20 billion for reinvestment over delivering savings of 10% or aroundImperial College Healthcare & Central the next four years. This represents a very £1,000 per month on respiratory chapterLondon Community Healthcare NHS significant challenge to be delivered prescribing for a practiceTrusts: Exploring how respiratory specialists through the detailed work the NHS hascan best support primary care to improve already undertaken on QIPP and the Further examples and more details aremanagement and reduce admissions. additional opportunities presented in Equity contained in the improvement stories. and Excellence: Liberating the NHS.Surrey Community Healthcare: How It is anticipated that these examples andteams can support earlier identification of In relation to the QIPP challenge, the NHS initial phases of work will demonstrateCOPD patients and prevent avoidable has been developing proposals to improve which elements of supported self care andadmissions. the quality and productivity of its services chronic disease management for COPD are since the challenge was first articulated in key components, and which approaches toNHS West Sussex: Supporting people to May 2009. The challenge is to ensure that implementation are most effective.self manage with clinical and behavioural the NHS continues to make quality happeninterventions during a period in which growth in expenditure on the NHS will be restricted despite increased demand.
  • 7. Executive summary 7Potential for future work • The optimal time and components of anIt is known that patients who understand effective review from both patient andwhat to do in the event of an exacerbation clinician perspectiveare more confident to seek help earlier and • Practical ways of implementing this andcan avoid admissions, while regular delivering it within existing resourcesmedication reviews and inhaler technique • How to optimise medicines use and thechecks can help reduce waste in prescribing. impact of doing so on cost, experienceIt is also acknowledged that while it is and use of other health care resourcescritical to have access to tools like plans, • The key components that need to be inreviews and templates to help patients place for patients to be able to effectivelymanage their condition, effective self-manage and the benefits of doing so Phil Duncan Director,management needs to be underpinned by a NHS Improvement -Lungset of skills, an approach and an This will allow the production of a modelinfrastructure that will allow delivery. These that demonstrates what needs to be incomponents can be considered as: place for care to be delivered effectively and how to implement it, to ensure that every• The resources that patients need minute of contact is used to maximum• What professionals need to do effect, every time.• The infrastructure that needs to be in place to facilitate to deliveryFor patients to be effectively supported to Catherine Blackabyself care and for professionals to deliver National Improvement Lead,chronic disease management successfully NHS Improvement – Lungeach of these components needs to be in Catherine Blackabyplace. The challenge now is to identify how Phil Duncan National Improvement Lead,best to implement this consistently, reliably Director, NHS Improvement - Lung NHS Improvement – Lungand cost effectively. Further work is alsorequired to identify the essential elementsand most effective means to put these intopractice, including: Components for effective delivery of supported self care and ongoing management• Planning for early intervention in the event of exacerbation• Medicines management and good inhaler Person who is informed, willing and able to self care technique• Adequate time for regular review that What the person needs encompasses what is important to both e.g. written self management plan; regular review; the clinician and the patient/carer and rescue medication; medicines; point of contact; supports self management knowledge; confidence; carer support• Skills to deliver support, education and treatment What we need to do e.g. inhaler technique checks; annual holistic review, patient led consultation, prescribing, listening, referral, identify risk,As a result the workstream will now focus support smoking cessation, planning for exacerbationson demonstrating how to improvemanagement and self care for people with What needs to be in placeCOPD to reduce admissions, optimise e.g. motivational interviewing skills, 30 – 60 minute appointments,medicines use and enhance patient data and information, access to specialist support, coding of patientsexperience by testing: and exacerbations, accurate diagnosis; ongoing training
  • 8. 8 Improvement stories: Improving patients’ ability to self manageImprovement stories: Improvingpatients’ ability to self manageKey messages• Just giving patients a plan and telling them what they should do probably won’t change behaviour• Effort, time and skills are needed to build rapport and focus on the person’s own goals and motivation so that they want to do the right thing• Different approaches work for different people• We think that the more time you invest up front with people, the less frequently you will probably see them – we are testing how to achieve this and how to optimise resources “ not the plan, It’s but the planning that is important. ”
  • 9. Improvement stories: Improving the patients’ ability to self manage 9‘Think ABC to self manage your COPD’ - onepractice’s approach to improve patients’management of exacerbationsVeor Surgery, Camborne, CornwallWhat were the issues? What we didThe Veor Surgery team wanted to test Initially, the team met and agreed its aimswhether chronic obstructive pulmonary and objectives; this was essential as itdisease (COPD) patients who had a self ensured all individuals stayed focused onmanagement plan, with courses of the task and would not get diverted intoantibiotics and steroids at home, could wider issues. Having identified the selfinitiate medication early and so reduce management plan the task was then tothe need for hospital admission. identify those patients who would be suitable for this type of patient pathwayThe team already knew that early and invite those individuals for anintervention reduces complications, but appointment. This took longer towanted to test whether a patient having arrange and organise and the impact ofa self management plan was sufficient patients who did not attend (DNA) wasand robust enough to enable them to significant as a longer appointment hadreliably and safely start their medication. been allocated.Questions that arose from this initial The team were anxious to identify Once patients had committed to theproposal included: suitable patients to test this approach. It programme they were assessed and base• Was it safe for patients to take this was imperative to work with those line data was taken using the COPD responsibility? individuals who would understand and Assessment Test (CAT) score. To alleviate• Would they understand? accept the responsibility for self any patient anxieties about the risk of• Would it create more work for the management, in order to minimise any rescue medication being inappropriately practice? risks. used, the practice established a safety net• Would patients feel empowered? system which entailed seeing patients The decision was then taken to develop two days after the self initiated therapy.Where did we start from? and adapt the existing self management This was to ensure the patients wereThe team initially drew up a process map, plan which had been generated by the managing and that there were no existinginvolving all team members and patient local hospital respiratory nurse. or further problems.representation, to determine whatcurrently happens along the patientjourney. This highlighted the need toidentify which patients were being Process mapping to understand what currently happens on the patient’s journeyadmitted and who provides what type ofcare at each stage, particularly followingadmission. The practice computerrecords provided the register of COPDpatients required and in order to includehouse bound patients the communitymatron was invited to be involved withinthe team. It was found that the practicerecords provided plenty of baseline datato initially start the project and it wasagreed that this was an accurate sourceof information.
  • 10. 10 Improvement stories: Improving the patients’ ability to self manageA recording system was initiated in order • Can patients understand the plan? If • Keep numbers small and manageableto identify major and minor significant not, why not? • Try and involve carers in theevents; it was also an opportunity to • Why don’t they follow the plan? consultation so they know andhighlight that the self management plans • Does early intervention increase or understand what to do and why. It canwere working and working safely. Once reduce practice work load? be frightening for the carer when theirdata started to accumulate they were • Are self management plans cost partner is unwell so ensure they knowthen in a position to reflect back on the effective? who to contact when, and what toprevious year’s exacerbations and for • Does early intervention reduce hospital look out foreach current year for a patient as it arose. admission? • Having a contact person and/or number • Are patients happy with managing their that is not the GP can encourageAs time went on, they worked through own conditions? people to get in touch. They may notseveral amendments to the plan, as • Have we done good or harm with self want to trouble the GP with theirchanges were identified based on management plans? query, but might feel happier talking topatients’ experience and feedback. a nurse, especially one they know deals What have we learnt? with them when they are wellWhere are we now? • Projects need to be flexible and beThe practice are now seeing patients adaptive as they are tried out in real life Above all try and answer theshortly after they have self medicated and • It is essential to have a close working question you have proposedare ensuring that they have used the self team who understands the aim of themanagement plan appropriately. It has project in order to be its driving force at the start of the project.been noted that some patients do not and to seek further improvementcontact the practice after starting • Keeping focused on the aim of the Contactmedication and when questioned explain project can be challenging, particularly Dr Peter Perkins, GPthat this is because they are feeling better as projects generate lots of data and Angie Bennetts, Advanced Nursenow and did not want to bother the then lots more questions Practitioner, Veor Surgery, Cornwalldoctor/nurse. As a single practice, the • Which of these questions need Email:numbers are small so it is difficult to answering and which are for new angie.bennetts@veor.cornwall.nhs.ukquantify or prove the impact on projects?admissions, but the team is confident • Coding in a consistent manner isthey have avoided admissions for some fundamental and recording of data onpatients. For example, one patient who the computer system is paramounthad several admissions over the previous • Finding time to explain plans isfour months successfully managed an challenging, but important, to ensureexacerbation at home just before that all patients understand theChristmas which was very rewarding for implications of a self management planthe team. • Safety nets are essential • Record all eventualities includingWork so far has identified other questions successes and failures in order to learnthat arise from initiating self management from themaction plans:
  • 11. Improvement stories: Improving the patients’ ability to self manage 11Embedding the use of effective selfmanagement approaches in primary careNHS BlackpoolWhat were the issues?Blackpool has a relatively high recordedprevalence of chronic obstructivepulmonary disease (COPD) at 2.6%, anestimated prevalence of 5.9%, a smokingrate of 31% and the 15th highestmortality rate for COPD out of 152Primary Care Trusts (PCTs). COPD makesa significant contribution to the area’slowered life expectancy and as such wasrecognised as an area for improvement.While Blackpool has the highest totalspend per 100,000 weighted populationof English PCTs, the proportion of spendin primary care is relatively low. All thesefactors suggested that there wassignificant scope to improve careplanning approaches in primary care witha view to increasing patients’ ability toself manage and so reduce unplannedadmissions.Where did we start from?• In 2007/08, there were 599 COPD What we did Patients also particularly liked the colour non-elective admissions costing The team developed a self management charts for sputum which they felt would £1.26 million plan through the respiratory steering help them to identify problems quickly• There was no formalised self group, which includes patient input as and the visual aid colour chart was management plan or approach in well as clinical representatives from reported as easy and simple to use. Local routine use across the PCT area. primary and secondary care and from a contact numbers and services were also• As part of a more integrated approach range of different disciplines. added as a specific request from both to COPD care, the team wanted to The self management plan was tested in patients and clinicians. improve both patient and clinician four practices with the ‘Breathe Easy education in order to establish self Group’ and adaptations were made Patients named the plan ‘My Breathing management and embed it within based on feedback before rolling out Book’ and it is coloured blue to make it primary care so patients are able to more widely. easily identifiable. manage their disease This highlighted issues around A series of educational events for terminology as well as identifying the stakeholders was provided, to ensure time and commitment required to there was good level of awareness and implement it. For example, patients understanding with regards to the self requested they change ‘MRC scale’ to management approach and plan before ‘breathlessness scale’, and ‘sputum’ rolling it out. rather than using the term ’phlegm’.
  • 12. 12 Improvement stories: Improving the patients’ ability to self manageWhere we are nowThe plan is initially being used to targetthose most at risk of admission and thecombined predictive model is being usedto look for the most vulnerable group ofpatients. It has been adopted so far byall 22 practices and while it is too early tosay what impact it has had on admissionrates overall, one GP dedicated threeeducational sessions to a patient who hadfrequent problems in the previous 12months. This has now prevented at leastone admission and embedded anapparent change in understanding andbehaviour for that patient.One practice is now testing groupsessions for patients as a means tominimise the impact of any failures toattend and to enhance the potential forpeople to share experiences and providesupport.Presently 40 plans are in place from theoriginal pilot with another 100 initiatedand data is still coming in from some ofthe practices. It is also being used bypulmonary rehabilitation, communitymatrons, and the acute Trust.To ensure that the self management plansare being delivered appropriately anduniformly, in order to underpin clinicaleffectiveness and promote change.changes to the way clinicians havetraditionally delivered learning are beingtested, including approaches used indiabetes structured education. To do this effectively clinicians need skills few practices. Standardisation in theSome key aspects of this are: in setting measurable goals, negotiation, consistent use of Read codes has been• To find out what is important to the and the ability to build rapport with the agreed with all practices in order to patient, not what you think is patients. facilitate data capture and analysis. This important for them in order to establish will also allow tracking of unplanned meaningful goals and life style changes To determine what impact the plan is admissions for patients who have been• For every piece of information you give, having, the team is currently monitoring given a self management plan and to make sure you get some information admission rates on a high level. However, explore and identify reasons in gaps in back to be meaningful the impact needs to be service or highlight any common trends.• Try not to solve problems for people identified at a more personal level so but encourage them to solve problems work is currently being undertaken with a for themselves
  • 13. Improvement stories: Improving the patients’ ability to self manage 13By focusing on these few practices the Similarly, the time required to deliverteam will also be able to quantify the effective care planning for selftime required to plan effectively with management is significant. For practicespatients and evaluate the impact on total and other teams to take on this approachcontact time as well as secondary care it requires compelling evidence that itadmissions. does pay dividends, as well additional guidance on how to do it with existingWhat we learnt resources.Involving all associated stakeholders,including patients in developing the plan Contactensures it has greater relevance to them Ros Inceand therefore there is greater Project Lead/Lead Nurse -commitment to its value and use. The Diabetes and Respiratorytesting process allowed clinicians to Email: rosalyn.ince@blackpool.nhs.ukexperience the potential of the plan, andto share knowledge and expertise withcolleagues at the launch of the project,which was more powerful than justproviding research data or evidence. TheGP chair of the PBC endorsed the selfmanagement plan and was activelyengaged in its launch and in promoting itto all practices in Blackpool. One clinicianreported that investment in time wasessential in order to reap the rewards.Clinical education is a vital component ifthis approach is to be properly embeddedin practice. Just providing the selfmanagement plans to patients will notensure its success. Clinicians need theskills and confidence to take a different,longer term approach in order to developrapport and instigate behaviour changewith patients.
  • 14. 14 Improvement stories: Improving the patients’ ability to self manageHow can support groups increase patients’ability to self manage?NHS Stoke on Trent and North Staffordshire Breathe Easy GroupWhat were the issues?The Primary Care Trust (PCT) is rated 11thhighest for COPD risk nationally withpeople 38% more likely to be admittedto hospital with COPD than elsewhere inthe UK. Stoke on Trent is an area of highsignificant deprivation where the publicare less likely to engage with statutoryauthorities, to initiate change in lifestyle,or engage in effective self care. Workingwith the British Lung Foundation and thelocal Breathe Easy North Staffordshire(BENS) patient support group offered adifferent route to increase self care andpromote healthy activity. It was also away to evaluate how support groups canbest add value for patients.Where did we start from? Members of the community respiratory team joining Breathe Easy North Staffordshire at• 2% recorded prevalence with estimated a chronic obstructive pulmonary disease (COPD) awareness raising event in October 2010 prevalence of 5% (rising to 6.3% by 2020)• Smoking prevalence of 30% compared to national average of 21% • A health care professional from the • Monthly recording was implemented in• Approximately 20 people from Stoke specialist community respiratory service order to capture the number of on Trent attended BENS meetings each provides regular input to BENS group members attending Breathe Easy North month at outset meetings to answer questions and offer Staffs meetings and the number of new• There was significant variation in additional advice members referral to/attendance at the local • Testing the impact of including referral • The Breathe Easy Group was involved in Breathe Easy group by practice to the group as part of active care the official launch of the community• Little knowledge and understanding of planning and self management for a respiratory service where they had a who attends groups, why people don’t group of patients who have had workshop to raise awareness of the attend, what is of greatest value to exacerbations group amongst healthcare professionals patients who do attend and no formal • Establishing impact measures on the recording of the benefits people get patient’s health status and confidence Where we are now from being part of a group • Capacity was built in within the Breathe • The attendance of a health care Easy group in order to support the professional at group meetings hasBENS did not monitor how those committee which included a new venue highlighted how many concerns peopleattending find out about the group or the and better opportunities to promote have, and their reluctance to approachnumbers of new members joining. the group via the community or voice these in ordinary consultations. respiratory service and at pulmonary Currently a list of frequently askedWhat we did rehab questions are being determined from• Established which practices do and do • The development of a Breathe Easy the meetings to identify any common not refer to the group and working to welcome pack to be given out to new themes and how they might be tackled raise awareness of the potential impact members, and formalised the process • Group members now have a slot on the peer support can have for their for recording new members and where pulmonary rehabilitation programme to patients, and how this can be tested they found out about the group highlight BENS group and the• Developed protocols to allow easy data additional support they can provide capture around membership
  • 15. Improvement stories: Improving the patients’ ability to self manage 15 • Personal health budgets are currentlyBENS membership by postcode - August 2010 being tested to see what impact they 7 have on supporting a person with COPD to self manage 6 Number of members 5 What we learnt • This is not a quick fix as the group only 4 meet once a month and it can take 3 time to witness changes. Measuring the impact has taken longer than 2 anticipated because of time factors and 1 issues around data access. Evidence on the group’s effectiveness depends both 0 Area A Area B Area C Area D Area E Area F Area G Area H Area I Other on patient feedback (for example around confidence and health status) Home postcode of members and measures of use of health care resources, such as appointments in primary care, and self management ofReferral source for members exacerbation. In order for this to 6 succeed strong links and two way 5 communication must be present with Number of members primary care and patient consent 4 • Patients are more likely to raise 3 concerns in an informal environment than in a formal consultation, which 2 may highlight issues relating to clinical 1 care elsewhere in the system • While groups are not for everyone, 0 more patients could benefit from Respiratory Newspaper Matron Rehab Hospital Not given Physiology participation if professionals are aware Potteries Shopping From another From a friend GP surgery Nurse of their existence and consistently Referral source promote theses groups within patient support information • It is proposed that further work overGroup membership by Stoke on Trent practice the next six months will define how support groups can enhance patient 6 engagement with self management 5 and will specifically target one or two Number of members key practices to focus work with 4 patients whose condition is more 3 difficult to manage. 2 Contact 1 Becky Gowers, Project Manager Email: 0 1 2 3 4 5 6 7 Sharon Maguire, Project Lead Practice Email:
  • 16. 16 Improvement stories: Improving the patients’ ability to self manageThe role of secondary care in increasing consistentuse of self management plans to reduce out patientattendance and emergency admissionSouthampton University Hospitals NHS TrustWhat were the issues?Self management plans were not widelyestablished across SouthamptonUniversity Hospitals Trust and the PrimaryCare Trust (PCT). Previously approacheswere variable, with disparate initiativesand lack of overall coordination. Patientswere confused about how to access careappropriately, particularly duringexacerbations. The goal was to work withcommissioners and other local providersto agree a uniform approach and acommon plan.Where did we start from?• High prevalence of chronic obstructive pulmonary disease (COPD) modelled at 6% with the PCT identified as a ‘hotspot’ for the highest rate of COPD admissions in the south of England• Less than 10% of COPD patients under the hospital COPD team had active self management plans A discharge support plan was also The possibility of developing a local,What we did developed which included a variety of comprehensive integrated service whichWe analysed attendance and admission measures that should be in place for all includes the hospital, community, primarydata for COPD patients using codes D39 COPD patients admitted. This work will care, social and emergency services isand D40 (admission with acute also allow evaluation of how easy it is to now being examined. The benefits ofexacerbation of COPD) and route of entry implement and the impact it can have on implementing this type of service wouldto hospital. readmissions. provide a patient centred approach focusing on supported self managementThis identified a group of 34 patients Where we are now with access to an array of supportwho accounted for 176 admissions in a A simple self management plan has been services via a single point 24/7.12 month period. Each of these patients developed for local use which it is hopedhad a one hour appointment with a can be more widely adopted.consultant and respiratory nurse, often in How best to bring psychological therapytheir own home to help the team input into the pathway is now beingunderstand why they were attending. It explored as part of the patientwas also an opportunity to help the assessment or follow up.patient to understand their condition Having identified a group of patients whobetter and what to do in the event of an frequently use urgent care, work has nowexacerbation. They were offered a begun with the local ambulance service inbespoke range of complex interventions order to improve use of oxygen alertand support in self management. These cards, emergency oxygen therapy andpatients have subsequently only had eight general communication around patientsadmissions in 12 months, a reduction of at risk of readmission.90%.
  • 17. Improvement stories: Improving the patients’ ability to self manage 17What we learntEstablishing the baseline data was timeconsuming, but was essential tounderstand:• Who is being admitted most frequently• Why they are being admitted, particularly from their point of view• What is happening in the course of an admission to explain variation in length of stay and readmission• Time spent with patients to explain their condition and understand their concerns pays dividends• There are gaps and overlaps in the patient journey that need to be understood in order to make best use of available resources• Ensuring a consistent discharge plan may reduce readmissionsIt is also vital to work with colleagues,commissioners and other partnersinvolved in service provision, to maximisethe resources already in place to ensure aconsistent and coordinated approachboth to self management and toexacerbation management.ContactDr Tom WilkinsonRespiratory PhysicianEmail:
  • 18. 18 Improvement stories: Managing COPDImprovement stories:Managing COPDKey messages• Consistent recording of data across the • It is important to work together to practice team is essential to allow improve management of COPD and stratification, monitoring of deterioration develop consistent and reliable and impact of changes in care approaches• Inhaler technique is a key area for • Understanding the current system and improvement in management – many why things do or don’t work well is patients do not maintain correct important before you start technique and many staff may not be • Change is slow and depends on people demonstrating correctly. There may be working together evidence of the cost effectiveness of • Data is essential. There is plenty of it using trainer devices to improve available but it is important to identify technique what is most useful and how best to• Take time to understand what is present it. Targeting patients or practices happening in your current system and with high resource use can help show who is doing what. You may be able to benefits more quickly do things more quickly, safely and reliably without additional resources• Significant variation across primary care may not be immediately apparent. Identifying low prevalence, high admission rates and prescribing performance can help target efforts for improvement
  • 19. Improvement stories: Managing COPD 19Systematic review of patients’ inhalertechnique and medication useVictoria Practice, Aldershot, HampshireWhat were the issues? • Common coding has been agreed forThe Victoria Practice is a five partner all practice team members in order topractice of 8,352 patients based in identify and record exacerbations ofAldershot. The practice was already COPD more accurately. It was decidedactively managing its chronic obstructive not to go back over previous records topulmonary disease (COPD) patients, but update coding as this would have beenwanted to ensure it was making best use a significant amount of work forof available resources to deliver consistent marginal benefit. This could alsohigh quality care. Evidence from a highlight an increase in exacerbationsprevious project on the Isle of Wight but will allow analysis of the proportionsuggested inhaler technique and that result in admissionmedication adherence could help improve • Recording data such as prescribingpatient experience and reduce frequency costs for respiratory medicines on aor severity of exacerbation, and use of statistical process control (SPC) charthealth care resources. The practice provides a good visual indicator of thewanted to explore how best to do this, impact over time of regular review, Where we are nowusing existing skills within the practice, optimising medication/device and • Identifying the best pathway forincluding their clinical pharmacist. improving inhaler technique patients within primary care and how a • Information from the practice system is practice team can best provide this.Where did we start from? now being used to evaluate the impact This includes looking at who does what• Prescribing costs for respiratory on admissions, medication use and and how consistent the way of working medicine of £11,000 per month cost, and potentially appointment is between different team members, in• Practice COPD prevalence: 1.58% (15.8 usage (routine vs. urgent) as the project order to achieve best use of skills and cases/1000 patients.) progresses resources for maximum patient benefit• Admission rate for COPD 10.6% (14 admissions in last 12 months)• Four patients had two or more admissions in previous 12 months SPC chart: Respiratory drug costs for Victoria Practice• Four patients accounted for nine admissions (out of a total from the practice of 14)• Inhaler technique baseline: 66 patients with GOOD technique (663H) ; Ten with POOR (663I)What we did• The practice systematically checked inhaler technique and medication review during the COPD annual check• Patients now complete a COPD Assessment Test (CAT) score at the start of their planned review and at recall after four weeks, where medication has been changed, to see what impact the change has had for them
  • 20. 20 Improvement stories: Managing COPDWhat we learnt Contact• Consistent coding in primary care Clare Watson teams is essential in order to Clinical Pharmacist Victoria Practice, understand current performance and Medicines Management Pharmacist impact on patient care or outcomes NHS Hampshire• Regular consistent review of inhaler Email: technique is essential as some patients do not maintain good technique and also for staff as they too need to be regularly updated• The use of devices to support good technique is cost effective and certainly reinforces correct methods• Patients need time to assimilate information: this team found it was good practice to allocate two thirty minute appointments with an interval of a few weeks allowing patients more time to consider what concerns they may have and how they are coping with medication or their condition, rather than one 60 minute appointment• Longer appointments create a risk if patients do not attend so it is important to plan how this can be managed• Other factors to consider: • How many patients have correct inhaler technique? and how many in the practice staff team? • How much is poor inhaler technique affecting patient adherence and prescribing costs? Poor technique may result in patients not using inhalers because they get no benefit or it could be increasing prescribing costs because medication is being wasted through ineffective use • How many exacerbations are patients actually having and how many result in admission? Good management may increase the number of recorded exacerbations but early identification and intervention could reduce the proportion that need to be admitted
  • 21. Improvement stories: Managing COPD 21How can respiratory specialists support primary careto improve management and reduce admissions?Imperial College Healthcare NHS Trust and Central LondonCommunity Healthcare NHS TrustWhat were the issues?• Imperial College Healthcare NHS Trust (ICHT) is the UKs first and largest Academic Health Science Centre. Since 2005, ICHT and Hammersmith and Fulham (H&F) Primary Care Trust (PCT) (now named Central London Community Healthcare NHS Trust) have been working in a coordinated partnership with the aim of improving services for patients with chronic obstructive pulmonary disease (COPD) and other chronic respiratory diseases• According to the Quality and Outcomes Framework (QOF) 2007/08 there are 1908 patients diagnosed with COPD in Hammersmith and Fulham (H&F), representing a prevalence of only 1%• This is below the national average (1.6%) and is thought to be a significant underestimate; modelled prevalence predicts that the total number should be in the region of 7,024 representing 3.7% prevalence • As part of a much wider approach the overall redesign of the delivery of care was• Wide variation in prevalence across all scrutinised in relation to how general practices, ranging from 0.5% respiratory specialist nurses and to 2.4% consultants could support primary care• Even practices meeting 100% of their to deliver evidence based chronic care, QOF targets as regards COPD diagnosis anticipatory care and case management show low actual prevalence compared for patients with COPD and asthma to that predicted working with clusters of practices• No breakdown of the known COPD population by disease severity Where did we start from?• 28% of the local population To ascertain a starting point a baseline (approximately 41,000 people) are assessment was undertaken of respiratory smokers competency with primary care staff which• Commissioners were looking for a included the delivery of workplace based reduction in COPD hospital admissions and modular teaching on spirometry, of 50% by 2013 and 30% reduction in COPD and asthma diagnosis and secondary care outpatient attendances management. A baseline assessment was by December 2011. A 10% reduction also established in relation to the QOF, in admissions and readmissions was COPD, asthma registers, and degree of targeted for July 2011 the National Institute for Health and Clinical Excellence (NICE)2010 compliance in management of COPD using the POINTS audit system. This has shown that management of these patients has significant scope for improvement.
  • 22. 22 Improvement stories: Managing COPDWhat we did It has now been agreed with the public • Case management and anticipatoryAs this was such a large scale project, it health team for them to provide the care for complex patients with onwardwas imperative that efforts were targeted required data to support the redesign referral to community consultant clinicand measurable. Initially process mapping process, as use of POINTS is not seen as a • A review of oxygen prescribing in thecommenced in relation to the open likely long term solution. The possibility of practice and gatekeeping methodsaccess spirometry and community comparing data from matched practices • Providing teaching sessions and ‘virtualconsultant clinics which calculated within not receiving RNS support has been clinics’ at practices, delivered bythe current systems the total amount of raised as a method of having some community respiratory consultantstime it took for a patient to be referred, control over the data.seen and treated could be up to 12 What we learntweeks. This also identified that the real Where we are now • It is important to understand what istime spent with the patient was only a There has been considerable change currently happening, and why. Thisfew hours. within the PCT which has resulted in the helped to highlight underlying problems level of administrative support not being with the location and perception of oneThe process mapping also identified areas as originally envisaged. However despite of the community clinics. It has alsoin the system which needed more this we have already witnessed a 27% assisted in targeting practices wheredetailed analysis in order to understand reduction in the number of acute additional support is required and wherewhy it took so long and where delays admissions for COPD in the first half of the greatest impact will be seencould be reduced or eliminated. In order 2010 compared to 2009/10, with a 20% • Early and sustained engagement of keyto highlight where the greatest impact reduction in secondary care clinic stakeholders, particularly commissionerscould be achieved on reducing the attendances. and primary care, is vital to the success ofnumbers of admissions in order to meet any integrated service; without this therecommissioner targets local practices were A significant programme of work is wouldn’t have been the investmentrated by highest total numbers of COPD planned over the next six months to necessary to move forwardadmissions and secondary care referrals. establish effective support to practices • Managing change is extremely slowA Pareto chart was then produced to which includes: and can prove to be difficult. Ensuringidentify which of the six practices should two way communication throughoutbe first to receive respiratory nurse • Establishing COPD and asthma clinics the process is essential. Changing thespecialist ( RNS) support. Gantt charts for to review patients (by priority) jointly way the community respiratory servicethe RNS were developed to ensure a with practice nurse/nominated GP works and communicating this toconsistent process when supporting • Introducing the use of templates to others was very challengingpractices. guide COPD/asthma reviews • Data is crucially important but robust • Assuring smoking cessation support for timely data is difficult to obtain; asSources of support were then determined those still smoking clinicians there is a need to haveto assist the progress of this work which • The introduction of appropriate READ ownership of data and takeincluded using pharmaceutical industry codes to prospectively record responsibility for it. There is plenty oftraining packages and POINTS for primary exacerbations information out there, and othercare data. Apollo templates are currently • The use of electronic pictorial COPD people can help you get it and use itbeing used for reviews as no funding was and asthma self management plans • Do not reinvent wheels; there areavailable for roll out of other versions. and prescription of rescue medication, resources already available for training, incentivised by local ‘QOF-plus’ analysis and templatesWork also commenced with the local arrangement • Change can sometimes be seen as hardpublic health team to identify appropriate • An onward referral system to work and is best achieved with a team,and feasible data collection. One of the community pulmonary rehabilitation, not aloneareas of work underway includes the incentivised by local ‘QOF-plus’provision of combined predictive arrangements Contactmodelling data to primary care to support • Home review of housebound/exempted Dr Irem Patelproactive case management of patients at patients Consultant Respiratory Physicianrisk of hospital admission. • A review of patients post exacerbation Email:
  • 23. Improvement stories: Managing COPD 23Earlier identification of COPD patients andpreventing inappropriate admissionsSurrey Community HealthcareWhat were the issues? What we didAcross Surrey there is a disparity of care • Process mapping event held resulting inand services provided, with a variance in an action planperformance and outcomes in both • GP champions were identified for theclinical and economic measures. Guildford cluster and Thames medicalHowever, there is also a widespread clusterdesire and shared philosophy of sharing • Cluster data charts were collatedbest practice and reducing inequalities. • Collaboration with the medicines management respiratory lead in SurreyThe prime challenge was to avoid on GP, Quality Outcome Frameworkunnecessary and costly admissions to (QOF) days to market localacute services, and to grasp the management guidelines (NICE 2010),opportunity provided to ensure the NHS Improvement - Lung pilot andprovision of high quality, efficient, South East Coast respiratoryequitable service is available to all across programmethe county for patients with chronic • North west paramedic COPD championrespiratory disease, so that improved identified • An audit was carried out of GPquality of care is delivered as available • An A4 patient held health record with surgeries which identified team inputbudgets reduce. essential respiratory information has for each surgery been developed for use across agencies • Agreed referral criteriaWhere did we start from? (message in a bottle and hospital • Breathe Easy information updated onAll data is shown as an actual figure for patient information systems) and project also including the review of theJuly 2010 and a rolling 12 months disseminated and implemented across new British Lung Foundation selfaverage which aims to reduce the effect north west and south west Surrey management literatureof the seasonal variation.• Admission rate (weighted for expected COPD prevalence) = 4 / 1000 An example of the dashboard used to monitor improvement over time population. Rolling 12 months average = 4.75 / 1000 population• 30 day readmission rate = 25%. Rolling 12 month average = 22%• 90 day readmission rate = 46%. Rolling 12 month average = 38%• Cost of emergency admissions = £199,536. Rolling 12 month average = £290,484• Bed days (weighted for expected COPD prevalence) = 17 / 1000 population. Rolling 12 month average of 32 / 1000.• Average LOS 4.2 days. Rolling 12 month average = 6.7 days• 13% of the last 12 months admissions were accounted for by multiple attenders (2 or more attendances)
  • 24. 24 Improvement stories: Managing COPDWhere we are now What we learnt• Progress has been slower than first • Reducing admissions cannot be expected due to staff changes and the achieved by one part of the pathway political climate working alone. Collaboration and• Issues have been uncovered around agreed processes across the acute, coding and releasing time to undertake community and primary care settings the project work and the ambulance trust are vital. If any• Work is ongoing to encourage and of these areas is disengaged or does evaluate the dissemination of self not have the capacity to work to management plans by the community change then the project will falter respiratory team • Information governance restrictions• Further work is needed to develop links make it very difficult to share with primary care and identify more GP information across organisations. COPD champions / leads within clusters Professionals must be aware of what (with a particular focus on the information they can and cannot share pathfinder consortia) without consent from the patient • In the current climate professionals areBelow is an example of the dashboard being pressed to deliver more with lessused to monitor improvement over time. resource; to ensure engagement youThis can be looked at by individual have to give evidence that your projectpractice level and includes a South East is worth their time. Provide data suchCoast wide comparator. as cost of emergency admissions, length of stay, readmission rates and prescribing spend • Change takes time and commitment; changing outcomes relies on changing mindsets, not just processes Contact Vikki Knowles Community Respiratory Team Lead, Consultant Nurse Email:
  • 25. Improvement stories: Managing COPD 25Supporting people with moderate or severe COPDto self manage through clinical and behaviouralinterventionsNHS West SussexWhat were the issues?The long term conditions programme hadundertaken a review of the admissionsand readmissions data for the PrimaryCare Trust (PCT). The data indicated thatreadmission rates remained high and thatlength of stay was prolonged. A decisionwas taken to ensure a range ofinterventions were available to all patientswith chronic obstructive pulmonarydisease (COPD) as part of their ongoingcare, to improve their ability to managetheir condition and to reducereadmissions.Where did we start from?Quarter 2 (Q2) 09/10• Average length of stay (LOS) 8.5 days• 30 day readmission rates were at 20%• 90 day readmission rates were at 38%• 135 bed days were used per 1,000 COPD population • One of the initiatives which is planned Where we are nowWhat we did is to implement a cognitive behavioural Due to the seasonal variation associated• Established the project team and therapy (CBT) group course specifically with COPD where we were in July and working groups for people with COPD. Work has begun where we are now in February is not• Established links with other similar with the Time to Talk team at Sussex comparable. Therefore Q2 09/10 with projects in the geographical area and Community NHS Trust who will be Q2 10/11 to ensure we are comparing across the country providing the service. So far referral like with like.• The recording of the project was set up criteria for this service have been on the NHS Improvement System to aid developed and work is ongoing to • LOS was 6.5 days for Q2 10/11, 2 days communication amongst the team as secure locations and publicise this lower than the previous years Q2 well as project planning and tracking service • 30 day readmission rates = 35% progress • Two more initiatives, post exacerbation although this dropped to 21% for Q3• Plans were developed for the reviews and personalised care plans are • 90 day readmission rates = 40% but as preparation phase: project plan, contact to be delivered in primary care. Four with 30 day readmission rates this has sheet, communication plan and data GP practices have been identified to be dropped for Q3 10/11 and now = 27% collection plan involved in developing this further • Using SPC analysis is helping us to see• A patient satisfaction survey was • Another scheme is to provide selected what is happening over time and where conducted using the LTC6 patients with telehealth units which is we can most effectively target our questionnaire amongst people with currently in the process of securing improvement efforts COPD in the county to establish a funding • Bed days per 1,000 COPD population baseline are steadily decreasing – this is likely to• This helped identify a number of issues be due to the reduction in LOS to help improve care and support for people with COPD
  • 26. 26 Improvement stories: Managing COPDWhat we learnt• One of the most important pieces of learning gathered from this project was the use of a robust diagnostic phase. This is needed to establish the current situation and to discover where the underlying problems might lie. It is also important in its use as a method of measuring and demonstrating improvements• The solutions must be tailored to population and specifically for the problem or gap identified• It is important to identify individual(s) to drive the project forward. This is particularly apparent in the current state of reorganisation in the NHS as it is needed to keep the momentum of the project going, keep the team engaged and keep it a priority• It is essential to have clear achievable objectives• It is sensible to take advantage of engagement approaches that have proven successful in the pastContactChloe DonaldGraduate Management
  • 27. Data 27DataWhy is data so important? Data is important for improvement projectsIf you don’t measure, how do you know because it is not satisfactory to say “it feelswhether what you are doing is better, better”, “I think it’s better”, or “it seemsworse or the same as it was last year? Or better”. We need to establish factual databetter, worse or the same as what everyone and measures to demonstrate what haselse is doing? been achieved.Data and measures are important todemonstrate that change has occurred orneeds to occur, and it also helps to focusimprovement work effectively. NHSImprovement focuses on the delivery ofquality measured improvements which arealigned to national priorities and strategies.In line with the national Quality InnovationProductivity and Prevention (QIPP) agenda,it is essential that all system changes aremeasured and recorded. Whether thechange was a success or did notdemonstrate the anticipated outcomes, westill need to demonstrate its effect andlearn from it.
  • 28. 28 What have we learned about data from the project sites?What have we learned about datafrom the project sites? National Programme Budget Interactive Atlas – (NHS Network connections only)1. Consider a needs assessment The Atlas of Variation, developed by Muir However the key learning is that often weapproach Gray’s Right Care workstream is a good do not know this variation exists, andThe overwhelming message from the starting point to highlight key clinical that by using the data more informationsites starting improvement work was that variation, and the NCHOD Programme is being uncovered about what isthere was difficulty in getting hold of Budget Atlas builds on this, providing happening in the and information. As work information on admissions, length of stay,commenced, sites reported limited access outcomes and overall respiratory spend, Analysts may be able to support and offerto data on their day to day activity, and plus functionality for mapping and standardised data, which accounts forvery poor access to overall information graphing the information at a PCT level. social status, age and sex factors, to showcovering the respiratory pathway. the variation with control applied for 2. Variation these factors.Fortunately, there are many resources A key message from the sites is how toavailable that can support sites to understand the variation within their local Projects are working to understand theunderstand and compare their services to systems, and to understand why there reasons behind variation by asking theothers, and many of these are freely and could be a difference in admissions, question "why" there is a difference.easily accessible. length of stay, or cost, between local This helps us better understand the areas, GPs and healthcare providers, in processes and provision of our services.A detailed list of data resources is order to improve the care for patients.available on the NHS Improvement - Lung Within the projects in Southampton, awebsite. Data is available nationally on Much of the variation may be for valid funnel plot and mapping technique wasprevalence, secondary care admissions and explainable reasons. Often, applied to show which practices hadand primary care that can be combined to socioeconomic factors, such as smoking significantly higher rates of admissionbuild a picture of local services. rates, can greatly influence the levels of compared to peers. It was found that healthcare need between different areas. these practices were located in areas of Yet, it cannot explain all the variation.
  • 29. What have we learned about data from the project sites? 29high social deprivation, and that theteams were generally less likely to engage Example of NHS Comparators mapping functionalitywith patients in these areas for fear ofcrime. The team agreed to explore whatother ways there may be to accesspatients in these areas.3. Prescribing savingsThere have been significant financialsavings demonstrated from simpleapproaches to medicines review.Respiratory medicines information can beobtained from the ePact system. Thereports generated by this system havebeen used by pharmacy advisors workingwith practices to monitor monthlyspending, and reductions in costs havebeen shown. Examples of how this isbeing used by Victoria Practice inHampshire are covered in theirimprovement story on page 19.4. Data sharing: local Having local access to HES, or the short time periods. For example, length ofagreements needed admissions providers collect prior to stay could be monitored on a per patientThe importance of sharing information submission to HES, would be valuable to basis.and data across the health community monitoring service improvement overhas been a key message from ourimprovement projects. Integrated carewill give the best outcome for patients, Example of statistical process control (SPC) chart – Charting can show processbut this message also applies to data. information, such as the length of stay, in a way that offers more detail than typicalWithout the sharing of information it is performance measures such as averages can offernot possible to show the whole pictureand what is involved in the care of thepatient. Healthcare providers need thedata for the whole pathway tounderstand how their improvement workis benefiting the patient.Hospital admissions data can be freelyobtained from sources such as HES(Hospital Episode Statistics), NHSComparators or in performance reports;however this is often aggregatedinformation, and can be up to threemonths old. The detail and timelinessrequired for improvement projects impliesthat sites should explore how to accessthe data locally, collaborating with theirlocal data teams.
  • 30. 30 What have we learned about data from the project sites?5. Primary care data doesn’t need tobe impossible Example of QOF dataPrimary care data is often seen as adifficult area to extract, and some of thesites found it difficult to access primarycare data at first. However, a number ofresources are easily available which canprovide a picture of primary care which isvaluable for improvement work.QOF data is useful, particularly forbuilding evidence and understandingaround the diagnosis and communityparts of the patient pathway. QOF data isparticularly valuable when compared toother indicators for COPD, such asadmissions, or expected prevalence.Comparing the proportion of patientspredicted to have COPD against actualreported COPD on QOF may highlightareas of unmet need, find missingpopulations, and suggest where to targetsupport and future work. NHS Comparators mapping exampleIt is important that sites using QOF reviewany exception reports, as it is possible toexclude patients.NHS Comparators has been muchdeveloped in the last year, and sites wereimpressed with the information itprovided, which helped provide basicbenchmarking and comparison forprimary care.Local investigation may reveal moreinformation. Project sites have foundvalue in interrogating the informationheld within primary care systems. Theimportance of accurate coding has beenemphasised by project sites, as they havelearned more about the exacerbations oftheir patients by ensuring coding iscorrect.
  • 31. What have we learned about data from the project sites? 31Primary care data can be explored using 6. Using primary care data to support 7. Know/love your analystthe reporting functions built into primary patient management Many of the project sites havecare systems, or using external tools, The Veor Surgery in Cornwall extracted emphasised the benefits from gettingexamples of which include the POINTS information using a locally created report, early support from a dedicated dataaudit tool from GSK, and the Optimum which provided information for all analyst. This has helped projects inPatient Care (OPC) tool used by the patients who appeared to have had an obtaining baseline information,Leicestershire project (see page 34 ). admission for COPD or respiratory supporting process mapping, andDetails on how to access these resources disease. Patient notes were compared to ongoing support to monitorare in the data guide on the NHS the extracted information from the improvement.Improvement website. practice system, and discrepancies were found with the numbers of exacerbations The key tips for getting and keeping and the coding of patients. analysts involved in projects are: GSK POINTS audit tool The site looked into why the coding was • Get your analyst involved early incorrect and the processes used to Sites that included analyst support from identify COPD patients. This led to the beginning had a head start with improved coding practice within the data, and rapidly built the evidence practice, improving how they identified base and understanding for the service COPD patients, ensuring that all change. Those sites without analyst exacerbations of COPD were monitored. support struggled to understand the importance of data, and later expressed The importance of accurate coding was regret as data revealed challenges or emphasised by this site, as they learned misunderstandings which could haveAccess to practice information is also more about the exacerbations of their been addressed sooner. Earlyessential for projects involved in End of patients by ensuring coding was correct. involvement helps ensure that you andLife (EOL) care work, as it is estimated the analyst have a sharedthat 14% of EOL registers may be COPD The Leicestershire project reviewed a vast understanding of the project.patients. Ensuring that this information is range of primary care indicators acrossaccessible, coded well, and used will the majority of GP practices in • Involving analysts closely with thesupport the EOL care pathway. Leicestershire County. This illustrated project, rather than an external different approaches to care, and functionThe NHS Information centre is planning different outcomes. It did not address This close involvement ensured theto improve access to GP information why there was a difference, but analysts had a greater understanding ofthrough the development of a national encouraged further investigation and the purpose of the projects, and theGP data extraction service. For further change to practice. analyst could input into the projectinformation visit the information centre goals to ensure the aims arewebsite at This project used the services of OPC. This measurable and achievable. It is also company supported the sites in extracting valuable, as it may reveal other sources primary care information, and of information or approaches which supplemented this with patient may be unknown to the project team. questionnaires. This detailed information highlighted where there was scope to improve practice, patients for whom treatment could be optimised and the variation in treatment offered across practices.
  • 32. 32 What have we learned about data from the project sites?• Seek formal support from the analyst and manager Analysts are often seen as a valuable resource, and as such their time may be protected. Some sites have found difficulties in maintaining analyst support in projects due to competing pressures elsewhere in the organisation. Sites have recommended that you ensure management support is in place for the improvement work and ensuring that analyst time is made available to support your work.• Look widely for your support People with access and expertise to data may not always be in analyst roles. Sites looking for information may wish to contact performance managers, clinical coders, data managers and contract managers, who exist in a variety of roles, supporting the management of Primary Care Trusts and provider trusts, with access to data being a core part of their roles.• Be clear on data requirements to information departments It helps to explain what you are trying to measure or demonstrate, as they may be able to suggest alternative indicators. As well as information analysts, involve all those involved in delivering care to contribute to a data collection plan.
  • 33. Improvement stories: Turning data into information for improvement 33Improvement stories: Turning datainto information for improvementKey messages• Code consistently, or you won’t be able to measure• You don’t need new data sources as there are plenty already available• Choose your measures of effectiveness carefully• Don’t be a victim of paralysis by analysis; use what you have, even if it is imperfect• Know what you are trying to achieve and what will indicate whether or not you are getting there. If it doesn’t tell you anything useful, don’t measure it. “ everything Not• Tools like ‘driver diagrams’, which were that can be originally developed by the IHI5, can help you determine what you need to measure and why, as illustrated in the counted counts, examples on the following pages. More information on ‘driver diagrams’ is and not available via the NHS Improvement website at: everything that counts can be counted. Albert Einstein ”
  • 34. 34 Improvement stories: Improving the patients’ ability to self manageUnderstanding variation in primary caremanagement of COPD - using practicedata to make the case for changeLeicestershire County & Rutland PCT in conjunctionwith Optimum Patient Care (OPC)What were the issues?Leicestershire County & Rutland Primary xxxxxxx xxxxxCare Trust (PCT) wanted to reduce thenumber of admissions and readmissionsfor chronic obstructive pulmonary disease(COPD). While national projections gavesome indication of need and demand, ithad become clear that there was littleunderstanding of how COPD was beingmanaged across primary care, and whatimpact this was having on admissions. Itwas difficult to know where efforts toimprove management and focusintervention would best be targeted. Theproject therefore aimed to create an initialbaseline of current performance whichwould allow personalised care plans to bedeveloped for each patient, to supportimproved management in primary careand so reduce admissions andreadmissions.Where did we start from?• The PCT had the second lowest recorded prevalence in the UK of 1.3% (ERPHO predicted prevalence: 2.6%)• There were 2,200 admissions for COPD in 2010 of which 600 were readmissions and the number was rising• Six out of 41 practices were achieving higher QOF rates for all COPD measures• An initial pilot survey indicated marked variation in recording of FEV1, COPD severity, exacerbation recording, smoking history, medication use, referral for pulmonary rehabilitation & other aspects of COPD care• This reinforced the recognition that there was no real corporate understanding of the issues around variation between ‘best’ and ‘worst’ performing practices or the impact this was having on secondary care or prescribing. Existing data sets gave only a limited understanding of what was happening across practices
  • 35. Improvement stories: Improving the patients’ ability to self manage 35What we did• The PCT worked with Optimum Patient Appropriateness of therapy by COPD severity Care (OPC), a not for profit (patients with only COPD diagnosis, not concurrent asthma and COPD) organisation, using their software tools 100 to collect practice clinical data 90• OPC’s clinical review service uses the DOSE index to identify those people 80 % of COPD patients with COPD who are at highest risk of 70 exacerbation and hospitalisation using 60 routinely recorded practice data and 50 questionnaire responses 40• The data extracted was also 30 automatically compared with PCT 20 agreed COPD rule sets based on 10 National Institute for Health and 0 Clinical Excellence (NICE) standards FEV1% Predicted FEV1% Predicted Overall• Discrepancies between current >80% 50 - 79% management and agreed optimal care Appropriate therapy Inappropriate therapy were automatically recorded and formed the basis of individualised patient reports that were fed back into the computer system• The next patient review can now be Long term therapy costs for based on the personalised specific misdiagnosed COPD patients could • The data analysis identified 35 recommendations for that patient that amount to £86k, a potential saving; patients with COPD diagnosis appear in their care plan depending on what their accurate who have had a hospital• 50% (41) practices participated in the diagnosis would be. Approximately admission and for whom there project 10% of the remainder were on no was a therapy recommendation therapy and 30% required optimisation of a LABA, LAMA, ICS orWhere we are now of prescribed therapy ICS/LABA• Information on patients from 41 • Key information from this approach • These 35 patients have practices has been analysed and that can help prompt improvement and experienced a combined total of individual patient reports provided to inform commissioning includes: 62 admissions those practices • Moderate (FEV1 %50 – 79) and • If these therapy recommendations• Of recorded COPD patients, 12.5% severe (30 – 49%) patients account lead to a possible 20% reduction (525 patients) were of unknown for significant numbers of in admissions – or 12 admissions - severity and 14.5% (609) patients admissions; improved management at an estimated cost of were, on the basis of recorded clinical efforts for this group could have £1,641.60 per admission this information, unlikely to actually have marked impact. 50 patients with could equate to a saving of COPD. 2711 patients had no FEV or COPD of moderate severity £19,699.20 FVC values within two years of accounted for 101 admissions, while diagnosis 38 patients with severe disease• Optimal therapy is not consistent across accounted for 73 admissions practices. Approximately 10% of those • Although smoking cessation is a high with a recorded diagnosis of COPD did impact intervention for COPD not have COPD on spirometric criteria management, referral for support is not consistent
  • 36. 36 Improvement stories: Improving the patients’ ability to self manageWhat we learnt• Providing information on performance Percentage of active smokers offered smoking cessation advice in the last year alone does not instigate significant change; primary care requires practical 100 input to support change 90• To provide a review covering all the 80 % of COPD patients points in the report requires at least 45 70 minutes and practices are likely to need 60 support to be able to deliver this 50• Primary care data can provide a far 40 more meaningful picture than through 30 Quality Outcomes Framework (QOF) 20 alone and can be used to support 10 commissioning and education plans as 0 well as to target intervention with B&L CN CS H&B Mr & H NWL O&W Overall practices more accurately, to improve (719) (574) (391) (308) (935) (1002 (285) (4124) management and reduce Locality admissions/manage exacerbations NO YES• Next steps are to identify how to present this information for maximum impact and which elements are most significant to different audiences. Also how to best support practices to deliver better care with the use of educational support and how to ensure commissioning plans take account of identified needs so funds can be directed accordinglyContactDermot RyanCOPD Lead, Leicestershire County andRutland PCT, Woodbrook Medical Centre,Loughborough LE11 1NHEmail:
  • 37. Improvement stories: Improving the patients’ ability to self manage 37Using information to target support to practices andpatients, in order to reduce variation in diagnosisand management of COPDNHS SheffieldWhat were the issues?Chronic obstructive pulmonary disease(COPD) is a top priority for NHS Sheffieldand forms part of their AchievingBalanced Health Strategy 3 (ABH), withpotential to reduce avoidable hospitaladmission and reduce the mortality andinequalities gap. Identified ‘hot spot’areas in Sheffield have a greaterprevalence of COPD, and there issignificant early mortality with a 14 yearmortality gap between the most affluentareas and the most deprived. As part ofa large scale service redesign the teamwanted to look at how to target supporteffectively to those areas where there wasevidence of greatest need, and reducevariation across the city. For example,Yorkshire and Humber Public HealthObservatory report that Quality OutcomeFramework rates for patients receiving a Graph quadrant example of how practices were identified though MOSAIC typeslung function test every 15 months range (risk stratification) and plotted admissions of practices within a consortiumfrom 34% to 100% across the city. The upper right hand quadrant identifies greatest risk of hospital admission; patients with COPD are three and four times more likely to be admitted to hospital, plotted against high ratesWhere did we start from? of admission.In 2008/09, 15% of patients with COPDhad an emergency admission, a rate alittle higher than the national average of14%. Strategic analysis had highlightedthe ‘hot spot’ areas and identified that67% of admissions profiled were firstadmissions. GP practice profiling hadhelped in identifying that certain practices Practice performancehad higher risk and higher levels ofadmission, but further work was neededto understand how COPD patients werebeing diagnosed and managed, in orderto identify what support was needed toimprove care.Work had already been undertaken insome parts of Sheffield using Navigatorsoftware to interrogate GP systems as itwas felt that this could be targeted at the‘hot spot’ areas to help improvemanagement.
  • 38. 38 Improvement stories: Improving the patients’ ability to self manage What we did The project nurses worked with the Total COPD Admissions per 1000 Having identified the key practices where practices to provide clinical support and population there was greatest scope for advice and to ensure patients were improvement, lead nurses approached reviewed and referred appropriately. them for agreement to install Navigator They were then in a position to be able to software which would allow analysis of provide easy to read data that illustrated their COPD patient population and where to the practices what the areas to to target effort. prioritise were, and why, and were also able to provide examples from practices The software could then be used to in other areas of the difference this identify patients who were at a high level approach had made. of risk of re-admission and those who needed a review, based on a range of The nurses’ role then was to help the indicators (see table below). practices identify their strengths and development areas, to enhance capability in house. This included: Indicators of risk and need used 1. Practice protocol for managing people by Navigator with COPD 2. Qualitative measures as identified by • Correct / quality assured Assessment of Respiratory spirometry measured and Management (ARM) questionnaire. recorded (i.e. VC, FVC, FEV1, 3. Identifying QOF data gaps, e.g. lung FVC/FEV1, VC/FEV1, actual values Inhaled corticosteroids function tests recorded in last 15 and percent of predicted, post- months, spirometry, immunisations, bronchodilator) inhaler technique • Assessment and documentation 4. For patients admitted to hospital, of COPD symptoms (exertional assessing suitability for pulmonary breathlessness, chronic cough, rehabilitation and follow up in primary sputum production, winter care or community clinic bronchitis, wheeze) 5. Reviewing the number of patients with • Patients treated outside NICE 3+ exacerbations and how they were pharmacological guidelines and managed NHS Sheffield formulary 6. Identification of patients suitable for • People at high risk of pulmonary rehabilitation following exacerbation (previous admission, Medical Research Council guidance steroid & antibiotic courses, low (level 3 and above) FEV1, MRC 3+ etc) • Risk stratification by severity • People with COPD with written individualised care plan
  • 39. Improvement stories: Improving the patients’ ability to self manage 39Where we are now What we learntEarly measures show a reduction in It took considerable time to engage theadmissions for COPD, suggesting that the practices in the more deprived and at riskinterventions are targeting patients and areas. It is likely that dedicated projectpractices successfully. management support would have helped progress this, particularly in the light ofThe nurses have successfully established significant staffing challenges andlinks with key hot spot practices identified organisational change that occurred infor this phase of work. They are now the early stages of the to use the information extracted tomake recommendations on and GP clinical leadership for the project hascontribute to further learning and helped drive change, including developing practicaltraining in areas such as spirometry, the Using stories and examples from otheruse of Navigator software to support best practices and patients helped to make thepractice, self management planning and case for using the software and what itthe use of Map of Medicine and clinical could do to make a difference in practice.templates. At a very practical level theycan promote and assist in the referral to “One gentleman who went tokey services, including smoking cessation, pulmonary rehabilitation hasactive programmes, communityrespiratory team, oxygen assessment, gone back to work”mental health support and end of lifesupport, based on the picture that the Nurses reported that they thought theirNavigator software provides of where care was good, but this approach hasimprovement is needed. This is indicated shown them there is still significant roomby an increase in referral to and uptake of for improvement.pulmonary rehabilitation and communityclinics. 50% more patients are gaining The reports from the system were very aaccess to group programmes and 50% powerful tool to highlight what wasmore are accessing domiciliary actually going on in the practice and whyrehabilitation. there was a need to work differently. The fact that help was available from a projectNext steps will include developing a team, from people who could build on anbooklet outlining key support for health established relationship with the practicecare professionals as a reference tool to team, probably made it easier to move onpromote ongoing good practice. to the next stage of actually implementing change. Contact Sue Thackray Deputy Head of Development Nursing – Respiratory Project Lead Email:
  • 40. 40 Top tips for COPD management projectsTop tips for COPD management projectsPatient reviews • People are motivated by different things.• You can have significant impact on If you take time to find out what will admissions by targeting your moderate motivate someone to change behaviour, COPD patients and increasing their you have a better chance of helping confidence in self management. You them need to ensure you have correctly • Group sessions for review or patient identified patients’ severity to be able to education can limit the impact if patients do this do not attend• If you have no other system for patient • Find out from patients what difference risk stratification, look at who accounts your care makes to their ability to for most use of resources e.g. manage or their evaluation of their own appointments, Accident & Emergency health using the CAT score or other tool. attendances, admissions, medicines. Use If what you are doing isn’t helping them, the Pareto principle to target effort; 20% it’s not their fault. Find out what would of people or problems may account for work for them 80% of resources• Allow enough time for a review – this could be 45 to 60 minutes. Shorter appointments mean you will not have time to listen to the patient and find out what they want and need to know, rather than what you want to tell them. If you get this right, you may avoid repeat appointments
  • 41. Top tips for COPD management projects 41Data and documentation Organisation• Record exacerbations consistently, using • If capacity is a problem, look at demand agreed Read codes. This will help and capacity or Lean approaches to see identify when people’s condition is how you can use existing resources more deteriorating and will help you evaluate efficiently or to quantify the gap whether more people are managing their • Templates are available for reviews and exacerbations without being admitted. self management plans. You do not If you do not do this, you will not find need to develop these from scratch, but the right patients when you search your you might want to adapt for local use to system ensure commitment from your• Do not just focus on the documentation stakeholders for self management or care planning. The time and the skills are most important• How good is your current system or the care you give? Look for indicators that actually tell you what is happening, not what you think is or should be happeningMedicines management• Liaise with your pharmacist colleagues to label rescue medication clearly so that people know what it is for, when to take it and what to do afterwards• Check all patients’ inhaler technique at every opportunity, and always before changing medication that does not appear to be working for them. It is essential to first check that you and all your team are demonstrating inhaler technique correctly; experience suggests that most people are not
  • 42. 42 Top tips for service improvementTop tips for service improvement• Every project needs someone to take • Focus your effort; you can not do overall ownership; even if they are not everything at once. Driver diagrams can formally called a ‘project manager’ help you identify which factors will help• Be clear about what your aim is and your move you towards your goal and Pareto overall objectives. Articulate what is you analysis can help you target your efforts want to achieve, by when, how much where they will have greatest impact and why, and make sure that everyone • Communication is vital to ensure that has the same understanding which the project team know what is avoids creeping outside the scope of happening and what their role is, and to what you have originally agreed maintain momentum and support.• Do not rush to implement a solution Choose appropriate means and intervals before you have truly understood the that fit the team you are working with, problem or the issue. Take time to and include other stakeholders too understand what really goes on at • Document your progress. This does not present and why. Process mapping and need to be complicated but will provide analysis can help with this stage a record of what, why, when and how• Engage your patients in the project and you did things that will be a useful value their engagement. Patients should reference as time goes on, and captures be at the heart of every improvement lessons learned and best practice for project future projects. It also helps you keep• Measure your baseline to determine track of what has been achieved to date. where you are starting from. What are This is especially helpful when you aiming for? Make the recording of change is incremental as it demonstrates measurement easy so that it is done how much progress has in fact been routinely. Use SPC (statistical process made control) or run charts to highlight the variation in your current system over time. If you do not measure, how will you know whether you have made an improvement or not?
  • 43. Top tips for COPD management projects 43• Test innovation and change on a small scale initially. We suggest using the Plan, Do, Study, Act (PDSA) cycle approach, as this minimises disruption if an intervention does not work, and helps to build commitment and sustainability if it does• Do not be afraid to ask for help or to fully utilise offers of support and resourceYou can find more information on theimprovement tools mentioned above, andother techniques to help manage yourproject and deliver change, on the NHSImprovement website
  • 44. 44 Contact detailsContact detailsVeor Surgery, Camborne, Cornwall Victoria Practice, Aldershot, Hampshire Leicestershire County & Rutland PCT“Think ABC to manage your COPD” – one Systematic review of patients’ inhaler Understanding variation in primary carepractice’s approach to improve patients’ technique and medication use management of COPD – using practice datamanagement of exacerbations to make the case for change Clare WatsonAngie Bennetts, Advanced Nurse Clinical Pharmacist, Victoria Practice / Dermot RyanPractitioner Medicines Management Pharmacist, NHS COPD lead LCR PCT, Woodbrook MedicalDr Peter Perkins, GP Hampshire Centre, Loughborough LE11 1NHTelephone: 01209 611 199 Telephone: 07789 271953 Telephone: 01509 239166Email: Email: Email: Blackpool Imperial College Healthcare NHS Trust & NHS SheffieldEmbedding the use of effective self Central London Community Healthcare Information to help target support tomanagement approaches in primary care NHS Trust practices and patients, to reduce variation in How can respiratory specialists support diagnosis and management of COPDRos Ince primary care to improve management andProject Lead / Lead Nurse – Diabetes and reduce admissions? Sue ThackrayRespiratory Deputy Head of Development NursingTelephone: 01253 651316 Dr Irem Patel Telephone: 07773 790915Email: Consultant Respiratory Physician Email: Telephone: 020 3311 7160NHS Stoke on Trent & North Email: NHS Improvement - LungStaffordshire Breathe Easy Group Catherine BlackabyHow can support groups increase patients’ Surrey Community Healthcare National Improvement Leadability to self manage? Earlier identification of COPD patients and Email: preventing avoidable admissions catherine.blackaby@improvement.nhs.ukBecky Gowers, Project Manager Website: 0116 249 5780 Vikki KnowlesEmail: Community Respiratory Team lead, Consultant NurseSharon Maguire, Project Lead Telephone: 01483 782000Phone: 01782 298286 Email: vikkiknowles@nhs.netEmail: NHS West SussexSouthampton University Hospitals Supporting people with moderate or severeNHS Trust COPD to self manage through clinical andThe role of secondary care in increasing behavioural interventionsconsistent use of self management plans toreduce OP attendance and emergency Chloe Donaldadmission Graduate Management Trainee Telephone: 01903 708513Dr Tom Wilkinson Email: chloe.donald@westsussexpct.nhs.ukRespiratory PhysicianTelephone: 02380 795341Email:
  • 45. Acknowledgements 45AcknowledgementsNHS Improvement - Lung would like to thank all the national improvement project sites fortheir contribution both to the ongoing work to improve care for people with COPD and tothis document.Thanks also go to Alex Porter, Senior Analyst at NHS Improvement and other members ofthe NHS Improvement - Lung team, for their expert input and to those project teammembers on the editorial team who produced this guide:Rachel Collins, Programme Manager, South East CoastChloe Donald, Graduate Management Trainee, NHS West SussexRachel Haffenden, Respiratory Service Clinical Lead, Central London Healthcare NHS TrustDr Irem Patel, Consultant Respiratory Physician, Imperial College Healthcare NHS TrustDr Peter Perkins, GP, Veor Surgery, Camborne, CornwallFor more information please contact Catherine Blackaby, National Improvement
  • 46. 46 Contact detailsReferences1 Calverley PM, Anderson JA, Celli B, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 007;356:775e89.2 Sutherland ER, Allmers H, Ayas NT, et al. Inhaled corticosteroids reduce the progression of airflow limitation in chronic obstructive pulmonary disease: a meta-analysis. Thorax 2003;58:937e41.3 Adams SG, Smith PK, Allan PF, et al. Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management. Arch Intern Med 2007;167:551e61.4 An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England, Department of Health 2011 Institute for Healthcare Improvement
  • 47. NHS NHS ImprovementCANCERDIAGNOSTICSHEART NHS Improvement NHS Improvement’s strength and expertise lies in practical service improvement. It has over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lung and stroke and demonstrates some of the most leading edge improvement work in England which supports improved patient experience and outcomes.LUNG Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spread quantifiable improvements with over 250 sites acrossSTROKE the country as well as providing an improvement tool to over 1,000 GP practices. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 Delivering tomorrow’s Publication Ref: IMP/comms021 - August 2011 ©NHS Improvement 2011 | All Rights Reserved improvement agenda for the NHS